Abstract :
A clinical trial was undertaken to evaluate the effect of Raktabasti to treat severe Anaemia in 39 patients with End Stage Renal Disease (ESRD).The average age of study subjects was found to be 44.74 years. 60 ml. of blood of a previously screened donor (a close relative) was given to the patient per rectally. The same procedure was repeated after 48 hours. The Hemoglobin rise after two Raktabasti given 48 hours apart was studied after next 48 hours. Raktabasti of total 120 ml blood has showed significant raise in the Hemoglobin level on an average by 1.65 gm/ dl. The present study proved that Raktabasti is an alternate, easier, safer and economical method of treating Anaemia in ESRD patients.

Introduction :
Chronic Renal Failure is a disease affecting the kidneys, in which there is a gradual decline in kidney function and urine output over a period of time. There is irreversible, progressive loss of kidney function. It is a patho-physiological process with multiple etiologies, resulting in to inexorable attrition of nephron number and function and frequently leading to End Stage Renal Disease (ESRD).
Chronic Renal Failure is caused by Diabetes, Hypertension, Glomerulonephrtis, recurring pyelonephritis (kidney infection), polycystic kidney disease (multiple cysts in the kidneys), autoimmune disorders such as systemic lupus erythematosus, urinary tract blockages and reflux, etc.

Samprapti :
According to Ayurved, the pathology behind renal diseases is disturbed Agni (metabolic Fire), due to which the food is not digested properly and thus formation of the vital components is disturbed. Increase in the use of anti-biotics, analgesics, anti-inflammatory drugs, Steroids leads to Dhatu Dusti .The changing lifestyle of people, sedentary work, eating fast food/junk food, incompatible food, constant stress and strain over indulgence of alcoholic drinks, and Ati guru, Ati sheet, Ati ushna, Ati ruksha, Vidahi, Abhishandhi, Asatmya, Akali, Aati matra, Ati drava, Aahar, Avyayam,Divaswap, Madyapan, smoking, tobacco chewing contributes substantively to Agnimandya, which is root cause of many diseases. Therefore as per Ayurvedic point of view Annavaha, Rasvaha,Udakvaha,-Raktavah, Medovah, Mutravah, Swedvah, srotes dusti contributes to kidney failure.
According to Ayurved, Vrikka is a Matruj organ,it is formed by cream portion of Rakta and Medadhatu. Vrikka is the moolsthanof Medovahsrotas. Vrikkavikarars have been associated with the cream part of Rakta- meda from mother, genetically linked and after birth; the host factors also do play a major role. In Chronic Renal Failure - there is depletion of the cream portion the dhatus from which Vrikka has been formed, i.e. Raktadhatu is depleted causing Raktakshaya/ Anaemia. This Anaemia is due to Raktadhatvagnimandya.

Epidemiology :
Chronic Renal Failure is one of the major non communicable diseases encountered in recent period. CKD (Chronic Kidney Disease) is a major risk factor for cardiovascular mortality, and kidney disease is a major complication of diabetes. Chronic Renal Failure is a worldwide threat to public health, but the size of the problem is probably not fully appreciated. Incidence of Chronic Renal Failure has been doubled in the last 15 years.
Chronic renal failure patient are having symptoms of lethargy, tiredness, weakness, loss of appetite, oedema, dyspnoea, dry skin and these symptoms may indicate Anaemia.
Chronic Renal Failure is encountered with suppressed erythropoesis resulting in to anaemia. Erythropoetin is a 30.4-kDaglycoprotein hormone secreted by peritubularinterstitial fibroblasts of the renal cortex in adult life. It is a primary hormone in Red blood cell production, without which Erythropoesis does not take place. In Chronic renal failure the production of Erythropoietin is suppressed, that causes Anaemia which is refractory to oral/ parenteral Iron supplements. Hence Erythropoietin hormone replacement therapy is prescribed by nephrologists in the treatment of CRF. However the treatment cost is very high and not within the reach of kidney patients who are mostly poor.
Here Ayurved offers best remedy to correct Anaemia with the help of Raktabasti. Charaka has enumerated various types of Basti and one of them is Raktabasti.
Rakte rakten pitte tu kashayswadu tiktakaihei I Charak Sidhha 8/25
Rakte rakteneti sarakte-atisaryamane Rakta bastirdeyah II Chakrapani
Wherever there is blood loss in large quantity, then Rakta-basti has to be given.
Tadev darbha mruditam raktam bastim pradapyeta I
Shyama kashmarya badri durvoushirehe shrutam payaha II Charak Sidhha 6/83
Before Raktabasti is given, the blood is to be mixed with Darbha, which acts as like an anticoagulant.
Charaka has further stated that fresh blood extracted from living deer,rabbit, ox, male buffalo, male goat etc. may be given orally (Rakta- prashan), to treat the conditions caused due to blood loss. Though Charaka prescribed Raktabasti for treating conditions occurring due to blood loss, I decided to explore its use in treating Anaemia in Chronic renal failure/ ESRD.
Sarvada sarvabhavanam samanyam vridhhikaranam I
Rhashetu visheshashchya, pravrittir-ubhayasya tu II Charak Su. 1/44
As per the principles of Samanesamanevridhhi, i.e. Like cures like, to save life due to heavy blood loss/ Raktakshaya (Anaemia),either Raktabasti or Raktaprashan may prove to be a wonderful lifesaving tool as prescribed by Charak in Raktatisarchikitsa. However Raktaprashan may not be acceptable to the recipient, in that case to save life due to blood loss/ Anaemia, either blood transfusion or Raktabasti these are the only two options available. Blood transfusion requires sophisticated blood bank, blood of correct blood groupof donor, matching- cross matching procedure, of donor and recipient blood, to avoid reactions.However here, the main advantage is that we can use donor's blood of any blood group in Raktabasti.Further, 60 ml. of blood given by Raktabastitwice, 48 hours apart, raises Hemoglobin concentration by 1.5 - 2 gm% within 48 hours. Blood loss causes Raktakshaya i.e. Anaemia and in C.R.F. patients Anaemia is refractory to iron therapy. Further in C.R.F. iron supplement may damage the kidney. I had already started research work on treating ESRD by Ayurvedic line of management, however I encountered with the Rakatakshaya that was not responding to the desired extent by Ayurvedic line of treatment,hence I decided to explore the use of the Raktabasti in treating Anaemia in these patients.

Advantages of Raktabasti over Blood transfusion

Sr. No.

Blood transfusion

Raktabasti

1.

Strict matching and cross matching of donor's blood and recipient blood is mandatory

Matching and cross matching of donor's blood and recipient blood is not at all required

No need of a blood bank. No anticoagulant, no cold chain required. An Ayurvedic physician and assistant/ nurse can perform it

4.

Large quantity of blood is required to cover up the blood loss andto raise the Hemoglobin concentration

Small quantity of blood is sufficient to raise the Hemoglobin concentration

5.

Costly

Economical

However this excellent Panchkarma procedure has been rarely used by the modern Ayurvedic experts. It may be due to undue phobia of introducing HIV infection/ Hepatitis B and C.Of course we have to take all universal precautions to avoid transmission of blood transmissible diseases.If these precautions are followed, Raktabasti does not have any extra risk than that of Blood transfusion.

It is experimentally proved that the material introduced by basti is detected in ileum and even up to duodenum and stomach. Therefore blood introduced via rectum ( Rakta basti) reaches 'Grahini' where Agni acts and forms the Rakta dhatu. Further the absorption potential of rectum is much more and the blood introduced by Raktabasti is readily absorbed. There is no urge to pass stools after giving Raktabasti. Even if the patient given Raktabasti passes stools there is no trace of blood found in the stool.

Aims and objectives :

To find out alternative to blood transfusion in treating Anaemia in End stage Renal Disease.

To explore role of Raktabasti in treating Anaemia in End stage Renal Disease cases.

Material and methods :
Study design: - A clinical trial was undertaken in 20 bedded Ayurvedic ward, Sassoon General Hospitals, Pune.
Study period: - June 2010 to Dec 2012
Study subjects: - 57Patients having End stage Renal Disease were admitted to 20 Bedded Ayurvedic ward of Sassoon General Hospitals, Pune and out of them 39 patients satisfying the selection criteria were included in the present study.

Selection of patients :

Patient selected were End stage Renal Failure cases suffering for more than six months,

Hemoglobin level < 6 gm%

Patients were not having piles/ hemorrhoids, anal fissure or local lesion in anal canal

Written consent was obtained and those who agreed, were included in the study

The relative of the patient is preferred as a voluntary donor. He/ she were screened for HIV, Hepatitis B and C, etc. as done routinely for the blood donors.

Investigations :
Renal function tests like Blood urea, serum Creatinine, C.B.C, LFT,Lipid profile , Urine RE estimation of serum electrolytes, Blood sugar- fasting and P.P., USG abdomen were carried out. Hemoglobin level was estimated by Sahli's method.
Thus 39 cases were diagnosed as cases of End stage Renal Disease with severe anaemia and those satisfying selection criteria were included in the study. Most of them had already put on Dialysis and needed frequent blood transfusions.

Table.1 Classification of study subjects as per age

Age group

No. of patients

25-29

2

30-34

3

35-39

5

40-44

11

45-49

7

50-54

4

55-59

3

60-64

2

65 and above

2

Total

39

Overall there were 31 males and 8 females in the study with mean age of 44.74 years (range 25- 73 years).

Etiology of Study subjects

Cause

No. of patients

%

Diabetes

13

33.3%

Hypertension

12

30.76%

Repeated U.T.I

3

7.69%

Polycystic disease

3

7.69%

Drug induced

3

7.69%

Urinary tract blockages and reflux

2

5.1%

Other causes

3

7.69%

Total

39

100%

In majority of study subjects the cause of CRF/ESRD was Diabetes and Hypertension, followed by Repeated U.T.I, Polycystic disease of kidney, drug induced nephritis ( H/O use of Steroids, antibiotics and analgesics). Other causes are related to change of life style,

Treatment prescribed :
The ESRD state as such was treated by Ayurvedic line of treatment principally by Deepan, Pachan, for treating Agnimandya; Mrudu virechana, Raktashodhan-Prasadhan for treating Dhatu dusti and Dhatavagnimandya; as per ayurvedic principles "mutras" is formed in Pakwashaya. Hence Basti chikitsa was given for improving Glomerular Filtration Rate.
For treating severe Anaemia, Raktabasti was given with following procedure :
The patient was asked to take Laghu- supachyaaahar/ breakfast before undergoing the procedure. It was strictly observed that the stomach of patient was not empty but rectum is empty. The donor and the recipient were kept lying on adjacent beds. The donor is pricked from median cubital vein, taking all the aseptic precautions, and 60 ml. of blood was taken out slowly with 18 no. needle attached to 100 ml.sterilized glycerin syringe. The recipient is lying on left lateral position. As soon as 60 ml. blood was taken out from the donor, the needle is removed and a No. 10 sterilized rubber catheter was fixed to the nozzle of the syringe. The catheter was lubricated with sterilized oil and immediately introduced per rectum. The syringe is emptied slowly and meanwhile patient is asked to take deep breathing.The same procedure was repeated after 48 hours. Hemoglobin level was estimated after 48 hours of second Raktabasti procedure.

Observations and Discussion :
It takes around 48 hours for formation of Rakta dhatu hence it was decided to study the Hemoglobin rise after 48 hours of giving the 2nd Raktabasti. It was observed that treatment with raktabasti showed significant raise in level of Haemoglobin by 1.65 (Â±0.08)gm/dl(df-38, t= 20.07,p<0.001).

Table No. 2: Rise in Hemoglobin level observed after RaktaBasti

Baseline Hb(MeanÂ±SD)

(N= 39)

Post Interventional Hb(MeanÂ±SD)

(N= 39)

Difference (MeanÂ±SE)

p value

5.43(Â±0.2) gm/dl

7.07(Â±0.5)gm/dl

1.65 (Â±0.08)gm/dl

<0.001

P value calculated using paired sample t test

Table 3. Classification of patients based on raise in Haemoglobin

Rise in Hemoglobin gm/dl

No. of patients

1-1.4 gm

12

1.5 - 1.9gm

19

2-2.5gm

8

In CRF/ESRD there is insufficiency of Erythropoetin hormone and patients put on Dialysis are given Inj. Erythropoetin on regular basis but still the Hemoglobin is not stabilized and such patients do require whole blood transfusion frequently. If we transfuse a unit of whole blood (450 ml) it raises Hemoglobin level by nearly 1 gm/ dl.
In the present study Raktabasti of only 120 ml blood has raised the Hemoglobin level by 1.65gm/ dl. Ayurvedic management of CRF/ESRD takes some more time to raise the Hemoglobin but here Rakta basti raises the Hemoglobin within 48 hours of raktabasti, giving opportunity to increase the efficacy of the Ayurvedic management to a great extent. Does Raktabasti triggers the production of Erythropoetin, is a question that needs to be addressed by a separate clinical research.
There were no adverse reactions or pyrexia and it went on very well in all the patients. This procedure was well accepted and tolerated by all the patients. Further, patients having earlier symptoms of lethargy, tiredness, breathlessness, loss of appetite etc., were relieved of these symptoms and felt sense of well being.

Follow up :
Hemoglobin was estimated every month for 6 months for each and every patient and it was found that the Hemoglobin level was stable in all the patients. . Raktabasti stabilized the hemoglobin and this was noteworthy accomplishment of the study. The study subjects were treated by Ayurvedic line of treatment; it might be a combined effect of Raktabasti and Ayurvedic treatment.
As already discussed above, these patients were on Ayurvedic line of treatment, (the details of which will be published in due course of time) and all were maintained on treatment without dialysis. Frequent dialysis lowers Hemoglobin, which did not happen in the present study as all patients were well maintained without dialysis.

Conclusion :
The present study proved that Raktabasti is an alternate, easier, safer and economical method of treating Anaemia in ESRD patients.

* Assistant Director of Ayurved, Nagpur region, Maharashtra
The Author has conducted this study at Sassoon Hospital,Pune and wishes to acknowledge the Dean,B J Medical College and Sassoon General Hospital,Pune for providing necessary facilities.Download Article